Cardiac Surgery in Patients with Liver Cirrhosis (CASTER) study: early and long-term outcomes

BACKGROUND: patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.METHODS: All adult patients with LC undergoing a CS procedure between 2000-2017 at ten Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) Score and Model for End-Stage Liver Disease (MELD) score. Early and medium-term outcomes analysis was performed in the overall population and according to CTP classes.RESULTS: The study population included 144 patients (mean age:66±9 years; male=69%). Ninety-eight, 20 and 26 patients were in CTP class-A, in early (MELD <12) or advanced (MELD >12) CTP class-B respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices and encephalopathy) and laboratory values (EGFR, serum albumin and bilirubin, platelet count) significantly worsened across the CTP-classes(p=.001). CABG or valve surgery (87% bioprosthesis) were performed in 36% and 50% respectively. Postoperative complications (especially AKI, liver complication and LOS) significantly worsened in advanced CTP class-B(p=.001). Notably, observed mortality was 3 or 4-fold higher than the EuroscoreII-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1- and 5-years cumulative survival in the overall population was 82±3% and 77±4% respectively. The 5-years survival in CTP class A, early- and advanced-B was 72±5%, 68±11% and 61±10% respectively(p=.238).CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in the early CTP classes medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.